Fiscal Year 2020 Department of Veterans Affairs Budget Request for the Veterans Health Administration

Chairman Takano, Ranking Member Roe, and Members of the Committee; on behalf of Brett P. Reistad, National Commander of the largest veteran service organization in the United States representing nearly 2 million members; we welcome the opportunity to comment on specific funding programs of the Department of Veterans Affairs (VA) in the federal budget.    

The American Legion is a resolution-based organization directed and driven by active Legionnaires who dedicate their money, time, and resources to the continued service of veterans and their families. Our positions are guided by 100 years of advocacy and resolutions that originate at the grassroots level of the organization – local American Legion posts and veterans in every congressional district across the United States. The headquarters staff of The American Legion works daily on behalf of veterans, military personnel, and our communities through our roughly 20 national programs and thousands of outreach programs led by our posts across the country.

As VA continues to serve the veterans of this nation, it is vital the Secretary has the necessary tools and resources to ensure they receive timely, professional, and courteous service – they have earned it. The American Legion calls on this Congress to ensure that funding for VA is maintained by implementing the president’s budget request. At a time when most federal agencies are experiencing a decrease in their respective budgets, the hope of The American Legion is that VA, with assistance from these critical committees, receives a much-needed increase.

 Sustainability, accountability, information technology (IT) integration and updates, Electronic Health Records (EHR), facilities repair, construction, staff recruiting, and healthcare are paramount programs requiring adequate funding. In the 115th Congress, The American Legion testified on the need for increased funding for each of the aforementioned programs.

Implementing the VA MISSION Act

“The Budget fully supports implementation of the VA MISSION Act of 2018 and provides veterans greater choice on where they receive their healthcare—whether at VA or through a private healthcare provider. The Budget consolidates all veterans’ community care programs into a single program, reducing bureaucracy and making it easier for veterans to navigate their healthcare needs.”        

-A Budget for a Better America, Trump Administration’s Proposed FY 20 Budget

The 2014 VHA Wait Time Scandal in Phoenix demonstrated to the veteran community the increased need for care in the community. Veterans desiring community care after the enactment of the Choice Act increased. The American Legion supported the Choice Program when it was added as a temporary emergency measure as part of the Veterans Access, Choice Accountability Act (VACAA) of 2014 because of our firsthand experience witnessing the need across the country.[1] 

In 2014, The American Legion established a dozen Veterans Crisis Command Centers (VCCCs) in affected areas (Fulton et al., 2018). VCCCs were established from Phoenix to Fayetteville and The American Legion spoke to hundreds of veterans personally affected by the scheduling problems within VA.  The Choice program provided an immediate short-term option, and provided an opportunity to learn how veterans utilized the program. At that time, The American Legion recommended gathering as much data as possible from veterans using the program to improve the ability of VA’s other existing authorities for care in the community.[2] Additionally, The American Legion supported the Veterans Choice Continuation Act, which continued the Veterans Choice Program (VCP) that was due to expire on August 7, 2017. Continuation of VCP ensured veterans within the VA healthcare system would continue to have the ability to access quality healthcare within their communities without interruption of services.

In 2018, a large percentage of veterans, many of which are proud members of The American Legion, voiced a preference to receive medical services closer to their homes. In response, Congress enacted the VA MISSION Act, a historic law that contains a number of policy priorities of The American Legion and other veteran stakeholders.[3] VA MISSION Act, principally, reforms the Department of Veterans' Affairs care programs, including Choice, into a single Veterans Community Care Program (VCCP). MISSION Act requires VA to promulgate new access standards, released earlier this year, and to develop strategic plans with completed market assessments to provide care to veterans under the new VCCP.

The budget includes $8.9 billion in 2020 and $11.3 billion in 2021 for the VA Medical Care program to implement the MISSION Act, including access standards that expand Veterans’ care options and reduce wait times for primary and specialty care.[4] The American Legion supports the President in adequately funding the MISSION Act to support VA’s implementation of a new consolidated community care program. We offer this support recognizing the president will continue to request, Congress must continue to appropriate, and VA must continue to properly allocate sufficient funding to maintain VA’s existing healthcare infrastructure. Further, our support relies on the understanding VA must expand capacity in locations where demand for care justifies additional VA infrastructure.

Ensuring Proper VA Staffing

“Each day, more than 380,000 VA employees come to work for America’s Veterans. These

employees have a close connection with Veterans – over 33 percent are Veterans themselves. The 2020 Budget supports an increase of 13,805 Full-Time Equivalent Employees (FTE) above the 2019 estimated level to expand access to healthcare and improve benefits delivery.”

-Department of Veterans Affairs – Budget in Brief 2020

The American Legion has long expressed concern about staffing shortages at VA and Veterans Health Administration (VHA) medical facilities including physicians and medical specialist staffing. Unfortunately, no easy solutions exist for VHA to effectively and efficiently recruit and retain staff at VA healthcare facilities. It is important to understand that simply providing additional funding will not resolve the issue of staff shortages. The American Legion believes access to basic healthcare services offered by qualified primary care providers should be available locally, and by a VA healthcare professional, as often as possible at all times.

While VA’s Academic Residency Program made significant contributions in training VA healthcare professionals, upon graduation many of these healthcare professionals choose a career outside the VA healthcare system. The VA will remain unable to compete with the private sector without changes to current hiring practices. To this end, The American Legion supports legislation such as The VA Hiring Enhancement Act and initiatives such as establishing its own VA Health Professional University. Such initiatives address the shortcomings in recruitment and retention of highly qualified physicians^[5]and allow VA to train their medical healthcare professionals to serve as a supplement to VA’s current medical residency program.^[6]

The American Legion understands filling highly skilled vacancies at premiere VA hospitals around the country is challenging. VA has a variety of creative solutions available to them beyond additional legislative action.  One such idea involves aggressively seeking public-private partnerships with local area hospitals. VA could expand both footprint and market penetration by renting space in existing hospitals enabling VA to leverage existing resources and foster comprehensive partnerships with the community.  Further, VA could research the feasibility of incentivizing recruitment at level 3 hospitals by orchestrating a skills sharing program that might entice physicians to work at level 3 facilities if they were eligible to engage in a program where they could train at a level 1 facility for a year every 5 years while requiring level 1 facility physicians to spend some time at level 3 facilities to share best practices.  Currently, medical staff is primarily detailed to temporarily fill vacancies. This practice fails to incentivize the detailed professional to share best practices and teach, but rather to hold down the position until it can be filled by a permanent hire.

Prioritizes Funding for Suicide Prevention

Reducing deaths by suicide among the Nation’s veterans continues to be VA’s top clinical priority. The Budget provides essential resources for VA’s suicide prevention programs and supports the expansion of key initiatives aimed at advancing VA’s National Strategy for Preventing Veteran Suicide.

-A Budget for a Better America, Trump Administration’s Proposed FY 20 Budget

Suicide prevention is a top priority of The American Legion, The Department of Veterans Affairs (VA), and the Department of Defense (DOD). Last summer, the nation’s largest organization of wartime veterans published a white paper report titled, Veteran Suicide.[7] The American Legion is deeply concerned by the high suicide rate among servicemembers and veterans, which has increased substantially since 2001.[8] The suicide rate among 18-24-year-old male Iraq and Afghanistan veterans is particularly troubling, having risen nearly fivefold to an all-time high of 124 per 100,000, 10 times the national average. A spike also occurred in the suicide rate of 18-29-year-old female veterans, doubling from 5.7 per 100,000 to 11 per 100,000.[9] These increases are startling when compared to rates of other demographics of veterans, whose suicide rates have remained constant during the same time period.

VA has taken great strides to reduce veteran suicide.Of particular note, VA expanded the Veterans Crisis Line (VCL), responding to500,000 phone calls every year, as well as thousands of electronic chats and text messages.Since its launch in 2007, through September 2018, VCL staff dispatched emergency servicesto callers in crisis over 93,000 times.[10]

VA also hired hundreds of Suicide Prevention Coordinators (SPCs), mental health professionals that specialize in suicide prevention. SPCs are based in VA medical centers and local community-based outpatient clinics all over the country. Over 80 percent of the SPCs are conducting five outreach activities per month for at-risk veterans.[11] These events provide opportunities for VA to connect to veterans who may have fallen through the cracks and are not currently seeking VA healthcare.

 The American Legion remains committed to working with Congress to reduce the high suicide rate among service members and veterans and is committed to finding solutions to help end this crisis. To ensure that all veterans are properly cared for at Departments of Defense and Veterans Affairs medical facilities, The American Legion, through Resolution No. 2 Suicide Prevention Program, has established a Suicide Prevention Program and aligned it under the TBI/PTSD Committee.[12] This committee reviews methods, programs, and strategies that can be used to reduce veteran suicide. The work of this body will help guide American Legion policy and recommendations.

President Donald Trump signed an executive order last month establishing a new task force aimed at empowering military veterans and ending the suicide epidemic among them.[13] The order, titled the "President's Roadmap to Empower Veterans and End a National Tragedy of Suicide," or (PREVENTS), will require top officials from multiple government agencies to coordinate a strategy to tackle the issue of veterans suicide and release recommendations to the president within the next 365 days. The American Legion believes this group led by Secretary Wilkie is a step forward, but we still have questions about how it will be executed and where the resources to support it will come from.

Congress must ensure sufficient resources are available for effective VA suicide prevention efforts. One death by suicide is one death too many. Funding for the aforementioned programs must be provided as well as money for new programs, including those to effectively treat individuals with previous suicide attempts, to deploy new interventions, and to identify those at higher risk of suicide. President Trump has called for a 9.5 percent increase in VA spending in 2020, up to a total of $216 billion. The American Legion appreciates the serious attention paid to this issue by the White House and urges Congress to appropriate these funds.

Provides Critical Funding for IT

“In 2020, OIT is requesting $4.343 billion, an increase of $240.0 million (5.8 percent) over the 2019 enacted budget. This requested increase will support critical investments to Veteran-focused development, IT modernization and transformational efforts.”

-Department of Veterans Affairs – Budget in Brief 2020

Department of Veterans Affairs (VA) Information Technology (IT) infrastructure has been an evolving technological necessity over the past 40 plus years, sometimes leading the industry, and sometimes trailing. Leading the field in 1978, VA doctors developed an electronic solution to coordinate and catalog patients healthcare long before their private sector colleagues, who were slow to follow, while some private physicians still refuse to automate today.The American Legion has been intrinsically involved with VA’s IT transformation from the inception of Veterans Health Information and Technology Architecture  (VistA) to being a pioneer partner in the concept and integration of the fully electronic disability claims process, as well as through the new telehealth project, Atlas. Atlas will enable remote examinations in selected American Legion posts.

IT automation is expensive to implement and expensive to maintain, especially while working on legacy equipment. As in all digital space, IT infrastructure advances so quickly that most IT infrastructure is outdated by the time it is fully implemented, and VA’s IT infrastructure is no different. This is the cost of doing business in a technologically advancing society. With this in mind, companies are turning to rented cloud-based resources and Software as a Service (SAS) to mitigate costs. These services have a lower up-front investment and negate the need for hardware maintenance and software upgrades in many cases.

IT is inextricably intertwined into many of the services we take for granted, such as; telephone systems, appointment scheduling, procurement, building access, safety controls, and much more.  Maintaining an up-to-date system is not a luxury, it is a necessity. The American Legion supports the continued effort by VA to update their systems. The president’s Budget provides $4.3 billion for essential investments in IT to improve the online interface between the veterans and the Department. This includes an increase of more than $200 million to recapitalize aging network infrastructure, to expedite VA’s transition to the cloud, and to support emerging VA MISSION Act of 2018 IT requirements.[14]

The American Legion continues to call on Congress to consider funding that enables VA to tie all of their IT programs together. This should be a seamless program capable of processing claims, managing veterans’ healthcare needs, integrating procurement needs so that VA leaders and Congress can analyze annual expenditures versus healthcare consumption. Additionally,  patient information must be integrated into their profiles ensuring seamless transition between the Department of Defense and VA.

Electronic Health Record Modernization (EHRM)

”The EHR is a high-priority initiative that would ensure a seamlessly integrated healthcare record between the Department of Defense and VA, by bringing all patient data into one common system.”

-A Budget for a Better America, Trump Administration’s Proposed FY 20 Budget

 

The American Legion, through resolution, has long endorsed and supported the Department of Veterans Affairs (VA) in creating a Lifetime Electronic Health Records (EHR) system. Additionally, The American Legion has encouraged both DoD and the VA to either use the same EHR system, or, at the very least, systems that were interoperable.

The American Legion recognizes the advantages of a bi-directional interoperable exchange of information between agencies. Collaborating with DoD offers potential cost savings and opportunities for VA. Opportunities include capitalizing on challenges DoD encounters deploying its own Cerner solution, applying lessons learned to anticipate and mitigate issues, and identifying potential efficiencies for faster and successful deployment. The American Legion supports the president’s Budget including $1.6 billion as part of a multiyear effort to continue implementation of a new EHR system. The EHR is a high-priority initiative that ensures a seamlessly integrated healthcare record between the Department of Defense and VA, by bringing all patient data into one common system, as such we call on Congress to fund it accordingly.

Medical Facilities

During FY 2012, VA unveiled the Strategic Capital Investment Planning (SCIP) program.  This ten-year capital construction plan was designed to address VA’s most critical infrastructure needs.  Through the plan, VA estimated the ten-year costs for major and minor construction projects and non-recurring maintenance would total approximately 60 billion over ten years. 

The American Legion is supportive of the SCIP program which empowers facility managers and users to evaluate needs based on patient safety, utilization, and other factors.  While it places the onus on these individuals to justify the need, these needs are more reflective of the actuality as observed by our members and during our visits.  VA has taken this process and effectively neutered it through budget limitations thereby underfunding the accounts and delaying delivery of critical infrastructure.

While failing to meet these needs, facility managers will be forced to make do with existing aging facilities. While seemingly saving money in construction costs, VA will be expending money maintaining deteriorating facilities, paying increased utility and operational costs, and performing piecemeal renovation of properties to remain below the threshold of major or minor projects. 

This is an inefficient byproduct of budgeting priorities.  The reality remains that the SCIP program is unlikely to be funded at levels necessary to accomplish the ten-year plan.  Therefore, this account must be increased to meet the short-term needs within the existing facilities.

Addresses Infrastructure Deficiencies

VA requests $1.2 billion for Major Construction operations, a decrease of $942 million (43 percent) over 2019 and similar substantial decreases in Minor Construction from $800 million to $399 million (50 percent).

-Department of Veterans Affairs – Budget in Brief 2020

Since 2003, The American Legion’s Veterans Affairs and Rehabilitation Commission members conduct a series of site visits to VA medical facilities and regional offices. While on site, Legionnaires visit with veterans, their families, and VA administrators and employees to discuss successes, challenges, and limitations at each site. Included in these System Worth Saving (SWS) reports are observations and challenges concerning infrastructure. In the 2018 System Worth Saving report, The American Legion noted multiple infrastructure issues with a number of facilities around the country, including Fort Harrison, Montana; Manchester, New Hampshire; Denver, Colorado; and Durham, North Carolina.[15]

Unfortunately, the types of issues found in these facilities are not isolated incidents and are too often found in VA facilities all around the country. For more than 100 years, our nation’s solution to care for those who have defended us has been to build a network of care facilities across the country. The VA system currently boasts more than 1,750 facilities with more than 5,600 buildings.

The current process to manage this network of facilities is the Strategic Capital Investment Planning program (SCIP). SCIP identifies VA’s current and projected gaps in access, utilization, condition, and safety. The SCIP planning process develops data for VA’s annual budget requests.  These infrastructure budget requests are divided into several VA accounts: Major Construction, Minor Construction, Non-Recurring Maintenance (NRM), Enhanced-Use Leasing, Sharing, and Other Investments and Disposal.  The VA estimates costs at approximately $60 billion.[16]

The American Legion is very concerned about the lack of funding in the Major and Minor Construction accounts. Based on VA’s SCIP plan, Congress underfunded these accounts and the president’s budget does not propose enough. Clearly, if this underfunding continues VA will never fix its identified deficiencies within its ten-year plan.  At current rates, it will take VA almost sixty years to address current deficiencies. VA currently has 24 partially funded major construction projects that need to be put on a clear path to completion and numerous additional projects that are in the design phase and have already received large expenditures in planning time, resources, and fees.

The American Legion also understands there is a discussion to refer to SCIP in the future as a “planning document” rather than an actual capital investment plan.  Under this proposal, VA will still address the deficiencies identified by the SCIP process for future funding requests but rather than having an annual appropriation, SCIP will be extended to a five-year appropriation, similar to the appropriation process used by the Department of Defense as its construction model.  Such a plan will have huge implications on VA’s ability to prioritize or make changes as to design or project specifications of its construction projects.  The American Legion is against this five-year appropriation model and recommends Congress continue funding VA’s construction needs on an annual appropriations basis.

The American Legion recommends Congress adopt the 10-year action plan created by the SCIP process.  Congress must appropriate sufficient funds to pay for needed VA construction projects and stop underfunding these accounts. 

Modernizes the Veteran Appeals Process.

“The Budget provides sufficient resources for the Board of Veterans Appeals and the Veterans Benefits Administration to implement the Veterans Appeals Improvement and Modernization Act of 2017, a new streamlined framework that will provide quicker decisions on new veteran compensation appeals and resolve the remaining legacy appeals inventory. The new framework will provide veterans with increased options to resolve their appeals and improve the timeliness of appeals decisions.”

 

-A Budget for a Better America, Trump Administration’s Proposed FY 20 Budget

The American Legion currently holds power of attorney on more than 1.3 million claimants. We spend millions of dollars each year defending veterans through the claims and appeals process, and our success rate at the Board of Veterans Appeals (BVA) continues to hover around 75 percent. Until President Trump signed the Veterans Appeals Improvement and Modernization Act of 2017 (Appeals Modernization Act or AMA) at The American Legion’s National Convention in Reno, Nevada, VA had a complex claims and appeals system.[17]

This “legacy” system divided jurisdiction amongst VA’s three administrations and the Board of Veterans’ Appeals (BVA). This confusing and complex process eventually led to extensive wait times and created a backlog.  At the time, it was estimated it would take over nine years to resolve the over 200,000 case backlog.[18]

Recognizing this indefensible state of affairs, The American Legion worked with other stakeholders, VA, and Congress to develop the Appeals Modernization Act. The law created a new

system with three review options:

• A “higher-level review” by a more senior claims adjudicator

• A “supplemental claim” option for new and relevant evidence

• An “appeal” option for review by the Board of Veterans’ Appeals

Now, claimants may choose the option that best suits their needs. This new framework reduces the time it takes to review, process, and make a final claim determination, all while ensuring veterans receive a fair decision. Additionally, the Appeals Modernization Act framework includes safeguards to make sure claimants receive the earliest effective dates possible for their claims.

The Appeals Modernization Act became fully effective earlier this year. The AMA sets forth specific elements that VA must address in its implementation. The American Legion believes working together with VA and Congress is vital to ensuring the success of the new appeals system. VA must provide stakeholders and Congress clear metrics to measure the progress and success of appeals and claims reform and strengthen Congress’s ability to hold VA accountable for meeting these metrics. The American Legion supports the funding in the president’s budget and urges Congress to appropriate this money and use its oversight authority to make sure stakeholder voices continue to be heard.

Better Care for Female Veterans

VA is anticipating and preparing for the increase in the number of women Veterans as well as for the accompanying complexity and longevity of their treatment needs.

 

-Department of Veterans Affairs – Budget in Brief 2020

In 2018, women Veterans comprised over 15 percent of active duty military forces and 19 percent of National Guard and Reserves. The number of women serving is growing, composing an increasingly large share of the military and veterans’ populations.[19] Women veterans now comprise about 10 percent of the total veteran population, and more than 7 percent of the veterans using VA healthcare services.[20] The 2015 Department of Veterans Affairs Women Veterans Report not­ed that the total population of women veterans is expected to increase at an average rate of about 18,000 per year for the next 10 years.[21]

VA needs to be prepared for a significant increase of younger female veterans, as those who served in the War on Terror separate from active service. Never before have so many women servicemembers been routinely assigned to combat zones. They sustain the same types of injuries as their male counterparts. The number of women enrolled in the VA system is expected to grow by 33 percent over the next three years.VA must ensure women veterans receive gender-specific healthcare to meet their needs across the entire network. The diverse population of women veterans using VA care require knowledgeable providers in women’s health to deliver comprehensive primary care services, including mental health, gender-specific care, and referrals for reproductive healthcare needs. Finding ways to ensure that these veterans are welcome and receive the services they deserve is vital to The American Legion.

VA needs to develop a comprehensive health-care program for female veterans that extend beyond reproductive issues. Bills like the Deborah Sampson Act and the Women Veterans Access to Quality Care Act are a step in the right direction. Provider education needs improvement. Furthermore, as female veterans are the sole caregivers in some families, services, and benefits designed to promote independent living for combat-injured veterans must be evaluated, and needs such as child-care must be factored into the equation. Additionally, many female veterans cannot make appointments due to the lack of child-care options at VA medical centers. Since the 2011 survey, The American Legion has continued to advocate for improved delivery of timely, quality healthcare for women using VA.  The American Legion is encouraged that the president’s budget recognizes the need for additional funding in this critical area, and has proposed an increase of $42 million almost 8 percent over last year’s authorization levels.

Medical Services

Over the past two decades, VA has dramatically transformed its medical care delivery system.  Through The American Legion visits a variety of medical facilities throughout the nation during our System Worth Saving Task Force, we see firsthand this transformation and its impact on veterans in every corner of the nation.

While the quality of care remains exemplary, veteran healthcare will be inadequate if access is hampered.  Today there are over 20 million veterans in the United States.[22]  While 8.3 million of these veterans are enrolled in the VA healthcare system, a population that has been relatively steady in the past decade, the costs associated with caring for these veterans has escalated dramatically.

Since 2010, VA enrolment has increased from 8.3 million to over 9 million^[23].  During the same period, inpatient admissions increased from 662 thousand to 764 thousand.  Outpatient visits also increased from 80.2 to 109 million.  Correspondingly, cost to care for these veterans increased respectively.  The increase during these years is a trend that dramatically impacts the ability to care for these veterans.

While FY 2010 numbers seemingly leveled off – to only 3 percent annual growth – will adequate funding exist to meet veteran care needs? If adequate funding to meet these needs isn’t appropriated, VA will be forced to either not meet patient needs or shift money from other accounts to meet the need.

Even with the opportunity for veterans from OIF/OEF to have up to 5 years of care following their active duty period, we have not seen a dramatic change in overall enrollee population. Yet The American Legion remains concerned that the population estimates are dated and not reflective of the costs.  If current mandatory healthcare mandates for veterans remain and with the Vietnam Era Veterans continuing to retire and needing healthcare that may no longer be provided by their employers, VA medical care will become enticing for a veteran population that might not have utilized those services in the past.

In order to meet the increased levels of demand, even assuming that not all eligible veterans will elect to enroll for coverage, and keep pace with the cost trend identified above, there must be an increase to account for both the influx of new patients and increased costs of care.

Military and Veteran Caregiver Services

The Budget also supports the VA MISSION Act of 2018’s expansion of the Caregivers program to include eligible veterans who incurred or aggravated a serious injury in the line of duty before September 11, 2001. Expansion of the Caregivers program would coincide with new information technology (IT) updates necessary to effectively manage the program.

 

-Department of Veterans Affairs – Budget in Brief 2020

The struggle to care for veterans wounded in defense of this nation takes a terrible toll on families. In recognition of this, Congress enacted, and President Barack Obama signed into law, the Caregivers and Veterans Omnibus Health Services Act of 2010. The unprecedented package of caregiver benefits authorized by this landmark legislation included training to ensure patient safety, cash stipends to partially compensate for caregiver’s time and effort, caregiver health coverage, and guaranteed periods of respite to protect against burnout.

The comprehensive package, however, was still not available to most family members who are primary caregivers to severely ill and injured veterans. Congress opened the program only to caregivers of veterans severely injured, either physically or mentally, in the line of duty on or after Sept. 11, 2001.

Finally, VA will begin to extend eligibility for the Program of Comprehensive Assistance for Family Caregivers to severely injured veterans of all eras, through a phased approach. First, VA must submit to Congress certification that the IT system relied upon by the program is prepared to accommodate a higher workload. Once the system is prepared, VA will begin processing applicants injured on or before May 7, 1975, in addition to those injured after September 11, 2001. Two years after this expansion, the program will accept all veterans severely injured in all eras.

The American Legion has long advocated for expanding eligibility and ending the obvious inequity that Caregivers and Veterans Omnibus Health Services Act of 2010 created. Simply put, a veteran is a veteran! All veterans should receive the same level of benefits for equal service. As affirmed in American Legion Resolution No. 259: Extend Caregiver Benefits to Include Veterans Before September 11, 2001, The American Legion supports the expansion to include all veterans who otherwise meet the eligibility requirements.[24]

The American Legion believes that providing expanded support services and stipends to caregivers of veterans to all eras is not only possible but also budgetary feasible and the right thing to do. We urge this committee and the U.S. Congress to allocate the required funding to continue and expedite the expansion of the caregiver program to all eras of conflict and veterans who should be in this program. The president’s FY20 Budget requests $720 million for the Caregiver Support Program, a $213.5 million (42 percent) increase over the 2019 level, to support over 27,000 caregivers through the Caregiver Support Program. The American Legion supports this proposal.

Ensuring Quality Care to Rural Veterans

“The budget maintains the strong level of funding for rural health projects at $270 million. As a complement to telehealth, VA is committed to improving the care and access for Veterans in geographically rural areas.”

 

                                    -Department of Veterans Affairs – Budget in Brief 2020

The American Legion’s System Worth Saving task force travels the country to evaluate VA medical facilities and ensure they are meeting the needs of veterans. From June 2017 to April 2018, the task force has been conducting site visits to VA medical facilities and town hall meetings to receive feedback from local veterans who utilize VA to receive their healthcare.

The Task Force, in its 18^th program year, is focusing on VA’s accomplishments and progress over the past decade and a half, current issues and concerns, and VA’s five-year strategic plan for several program areas. These areas of focus are VA’s budget, staffing, enrollment/outreach, hospital programs (e.g. mental health, intensive care unit (ICU), long-term services and support, homelessness programs) information technology and construction programs. 

During each site visit, a town hall meeting is hosted by an American Legion Post. The town hall meetings have consistently illustrated that veterans are worried VA has turned a deaf ear to their concerns and is intentionally ignoring their complaints.  We have seen firsthand where VA has closed intensive care departments, downgrading emergency departments to urgent care clinics, or has proposed to closed or reconfiguring hospital services under the guise of “realigning services closer to where veterans live.”

The American Legion urges Congress to evaluate VA’s plan in rural areas and to stop VA from closing hospitals and community-based outpatient clinics unless existing requisite community services are meet or exceed that VA currently provides to veterans.

In addition to ensuring improvements to infrastructure in rural areas, Congress must support increased funding to support telehealth. As the largest integrated healthcare system in the United States, the VA provides telehealth at more than 900 sites across the country in over 50 areas of 
specialty care. In 2017, 45 percent of Veteran who received care via telehealth lived in rural areas, yet many Veterans are limited from this option due to lack of availability of reliable connectivity or technology.

The American Legion, Veterans of Foreign Wars, the U.S. Department of Veterans Affairs (VA) and Philips have partnered to bring VA healthcare to veterans through VA’s “Anywhere to Anywhere” program. This program will allow veterans to be examined by a doctor in a familiar setting, their American Legion posts.

Through Project Atlas, Philips will install video communication technologies and medical devices in selected American Legion posts to enable remote examinations through a secure, high-speed internet line. Veterans will be examined and advised in real time through face-to-face video sessions with VA medical professionals, who may be located hundreds or thousands of miles away. The program enables the “Anywhere to Anywhere” VA initiative to benefit veterans who would otherwise need to travel to receive care.

The president’s proposed budget requests $1.1 billion for the total Telehealth program, an increase of $105 million above the 2019 level. In 2021, VA is requesting $1.7 billion, an increase of $623 million above the 2020 level. The American ardently supports this initiative and urges Congress to appropriate funds to bring affordable VA Healthcare to veterans in rural areas through this program.

Mental Health

Post-traumatic stress disorder and traumatic brain injury are the signature wounds of today’s wars. Both conditions are increasing in number, particularly among those who have served in Operation Iraqi Freedom and Operation Enduring Freedom.  The President’s request for a 4.7 percent increase in funding will provide find much-needed funding dedicated to this area.  While Veterans who served in Iraq and Afghanistan make up only a small percentage of VA’s patient population they require a disproportionate amount of VA specialized mental health services. There are nearly 3.5 million veterans who served after September 11, 2001. The need for specialized mental health services will only grow.

In July 2010, VA took significant strides towards assisting veterans suffering from PTSD.  The liberalization of regulations relaxed the need for veterans to provide proof of a PTSD stressor; instead, veterans only needed to prove a “fear of hostility.”  Further, since 2012, VA has increased staffing of new mental health providers, made efforts to improve wait times for mental health services, and removed numerous barriers to care.

While The American Legion acknowledges advancements in this area, we also know there is significant room for improvement.  From development of PTSD claims, through compensation and pension (C&P) examinations, to ultimate adjudication, The American Legion accredited representatives routinely see errors throughout the process.  Furthermore, if a veteran seeks service connection for a physical condition that manifested secondary or was aggravated by PTSD, veterans routinely are faced with a difficult journey.

VA has hired more than 3,900 new mental health providers yielding a net increase in VA mental health staff of over 1,000 providers, since July 2017. However, during that time there has been a massive influx of veterans into the system, with a growing need for psychiatric services. With over 1.5 million veterans separating from service in the past decade, nearly half have not utilized VA for treatment or evaluation. The American Legion is deeply concerned about nearly 750,000 veterans who are slipping through the cracks unable to access the healthcare system they have earned through their service.

The American Legion believes VA must focus on head injuries and mental health without sacrificing awareness and concern for other conditions afflicting servicemembers and veterans. As an immediate priority, the VA must ensure staffing levels are adequate to meet the need. The American Legion also urges Congress to invest in research, screening, diagnosis, and treatment of PTSD and TBI.

The American Legion recently published in, The Road Home, we believe VA must continue to search for the most effective treatment programs for veterans with comorbidities of PTSD, and TBI with substance use disorder (SUD) and chronic pain.[25] We should also seek to develop treatment options including Complementary and Alternative Medicine (CAM) for veterans who are newly diagnosed. Providers in VA must take care to prevent at-risk veterans from becoming dependent on alcohol or drugs used to “self-medicate.”

Through Resolution No. 160 Complementary and Alternative Medicine, Congress is urged to provide oversight and funding VA for innovative, evidence–based, CAM in treating various illnesses and disabilities. The president’s proposed budget requests $9.4 billion for Veterans’ mental health services, an increase of $426 million (4.7 percent) above 2019. The American Legion supports this action. Additionally, The American Legion remains committed to working with the VA in any way possible to move the VA toward their goal of becoming a fully integrated paperless system.[26] 

Medical Support and Compliance

The Medical Support and Compliance account consist of expenses associated with administration, oversight, and support for the operation of hospitals, clinics, nursing homes, and domiciliaries.  Although few of these activities are directly related to the personal care of veterans, they are essential for quality, budget management, and safety.  Without adequate funding in these accounts, facilities will be unable to meet collection goals, patient safety, and quality of care guidelines. The American Legion has been critical of programs funded by this account.  We remain concerned patient safety is addressed at every level. 

State Veteran Home Construction Grants

Perhaps no program facilitated by the VA has been as impacted by the decrease in government spending than the State Veteran Home Construction Grant program.  This program is essential in providing services to a significant number of veterans throughout the country at a fraction of the daily costs of similar care in private or VA facilities.  As the economy rebounds and states are pivoting towards resuming essential services, taking advantage of depressed construction costs, and meeting the needs of an aging veteran population, greater use of this grant program will continue.  As our baby boomer population continues to transition into retirement, many more of these veterans are retiring to state veteran homes due to their excellent reputation for care and cost.  The popularity of these retirement options will cause any surplus of space to become consumed.  The American Legion encourages Congress to increase the funding level of this program.

Medical and Prosthetic Research

The American Legion believes VA research must focus on improving treatment for medical conditions unique to veterans.  Because of the unique structure of VA’s electronic medical records (VISTA), VA Research has access to a great amount of longitudinal data incomparable to research outside the VA system.  Because of the ongoing wars of the past decade, several areas have emerged as “signature wounds” of the Global War on Terror, specifically Traumatic Brain Injury (TBI), Posttraumatic Stress Disorder (PTSD), and dealing with the effects of amputated limbs.

Much media attention has focused on TBI from blast injuries common to Improvised Explosive Devices (IEDs) and PTSD.  As a result, VA devoted extensive research efforts to improve the understanding and treatment of these disorders. Amputee medicine has received less scrutiny but is no less a critical area of concern. Because of improvements in body armor and battlefield medicine, catastrophic injuries that in previous wars would have resulted in loss of life have led to substantial increases in the numbers of veterans who are coping with loss of limbs.

As far back as 2004, statistics were emerged indicating amputation rates for US troops were as much as twice that from previous wars.  By January of 2007, news reports circulated noting the 500^th amputee of the Iraq War. The Department of Defense’s response involved the creation of Traumatic Extremity Injury and Amputation Centers of Excellence, and sites such as Walter Reed have made landmark strides in providing the most cutting-edge treatment and technology to help injured service members deal with these catastrophic injuries.

America’s disabled veterans depend on VA maintaining its reputation as the leader in prosthetics care and service. VA has a reputation in the United States and around the world of providing the best possible prosthetic care to its disabled veterans. However, The American Legion remains concerned that once these veterans transition away from active duty status to become veteran members of the communities, there is a drop-off in the level of access to these cutting edge advancements.  Ongoing care for the balance of their lives is delivered through the VA Healthcare system, and not through concentrated active duty centers. 

Reports indicate the state of the art technology available at DOD sites is sometimes not available through a VA Medical Center.  With so much focus on “seamless transition” from active duty to civilian life for veterans, this is one critical area where VA cannot afford to lag beyond the advancements reaching service members at DOD sites.  If a veteran can receive a state of the artificial art limb at the new Walter Reed National Military Medical Center (WRNMC) they should be able to receive the exact same treatment when they return home to the VA Medical Center in their home community, be it in Gainesville, Battle Creek, or Fort Harrison.

American Legion contact with senior VA healthcare officials has concluded that while DOD concentrates their treatment in a small number of facilities, the VA is tasked with providing care at 152 major medical centers and over 1,700 total facilities throughout the 50 states as well as in Puerto Rico, Guam, American Samoa and the Philippines.  Yet, VA officials are adamant their budget figures are sufficient to ensure a veteran can and will receive the most cutting edge care wherever they choose to seek treatment in the system.

The American Legion remains concerned about the ability to deliver this cutting edge care to our amputee veterans, as well as the ability of VA to fund and drive top research in areas of medicine related to veteran-centric disorders.  There is no reason VA should not be seen at the world’s leading source for medical research into veteran injuries such as amputee medicine, PTSD, and TBI.

The American Legion urges Congress to ensure appropriations are sufficient to meet the prosthetic needs of all enrolled veterans. We believe the VA must continue to protect all funding for prosthetics and sensory aids. The VA must maintain a dedicated, centralized funding prosthetic budget to ensure the continuation of timely delivery of quality prosthetic services to the millions of veterans who rely on prosthetic and sensory aids’ devices and services to recover and maintain a reasonable quality of life. The American Legion is skeptical of the reduction of funding for FY 20 from FY 19 in the president’s proposed budget and urge Congress to, at a minimum, maintain funding.

Medical Care Collections Fund (MCCF)

In addition to the aforementioned accounts which are directly appropriated, medical care cost recovery collections are included when formulating the funding for VHA.  Over the years, this funding has been contentious because they often include proposals for enrollment fees, increased prescription rates, and other costs billed directly to veterans.  The American Legion has always ardently fought against these fees and unsubstantiated increases.

Beyond these first party fees, VHA is authorized to bill healthcare insurers for nonservice-connected care provided to veterans within the system.  Other income collected into this account includes parking fees and enhanced use lease revenue.  The American Legion remains concerned that the expiration of authority to continue enhanced use leases will greatly impact not only potential revenue but also delivery of care in these unique circumstances.  We urge Congress to reauthorize the enhanced use lease authority with the greatest amount of flexibility allowable. 

It would be unconscionable to increase this account beyond the previous levels that were not met. To do so without increasing co-payments or collection methods would be counterproductive and mere budget gimmickry.  While we recognize the need to include this in the budget, The American Legion cannot condone a budget that penalizes the veteran for administrative failures.

Advance Appropriations for FY 2020

The Veterans Health Administration (VHA) manages the largest integrated health-care system in the United States, with 152 medical centers, nearly 1,400 community-based outpatient clinics, community living centers, Vet Centers and domiciliary serving more than 9 million veterans every year. The American Legion believes those veterans should receive the best care possible.

The needs of veterans continue to evolve, and VHA must ensure it is evolving to meet them. The rural veteran population is growing, and options such as telehealth medicine and clinical care must expand to better serve that population. Growing numbers of female veterans mean that a system that primarily provided for male enrollees must now evolve and adapt to meet the needs of male and female veterans, regardless whether they live in urban or rural areas.

An integrated response to mental healthcare is necessary, as the rising rates of suicide and severe post-traumatic stress disorder are greatly impacting veterans and active-duty servicemembers alike.

If veterans are going to receive the best possible care from VA, the system needs to continue to adapt to the changing demands of the population it serves. The concerns of rural veterans can be addressed through multiple measures, including expansion of the existing infrastructure through CBOCs, MISSION Act initiatives, improvements in telehealth and telemedicine, improved staffing and enhancements to the travel system, and other innovative solutions.

Patient concerns and quality of care can be improved by better attention to VA strategic planning, concise and clear directives from VHA, improved hiring practices and retention, and better tracking of quality by VA on a national level.

And finally, mandatory funds must be included in Advanced Appropriations along with full discretionary funding of all VA accounts. Veterans and dependents having their compensation and disability checks delayed because Congress refuses to pass an annual budget before being forced to close the federal government is reprehensible.  Pass full advanced appropriations now.

Conclusion

Implementing the VA MISSION Act will require more resources than have been provided through regular appropriations in FY19 and it will cause care appropriation needs by the VA for future fiscal years. MISSION Act changes how VA purchases health services for veterans from community providers, is projected to increase veterans’ enrollment in the VA healthcare system, and increase veterans’ utilization and reliance on VA as a direct provider of care. Any and all future funding levels must reflect this as part of the plan, not wait until VHA is in crisis.

Greater emphasis needs to be placed on VA’s hiring and incentives, and if additional resources are needed to secure key providers like psychologists and physician’s assistants, then VHA must be provided with the funding needed to make those critical hires. That is the long-term key to ensuring that veterans get the care they need in a timely fashion in the system that is designed to treat their unique wounds of war.

For Caregivers, older veterans’ participation is unlikely to fluctuate, caregivers of older veterans likely will. Younger veterans tend to rely consistently on a spouse or a parent for care. Older veterans are less likely to have a spouse still capable of the physical demands of providing daily care.VA must be able to accommodate rotating caregivers, providing adequate and relevant training needed to sustain their veteran and maintain the caregivers own health as well.

VA must continue to research the most effective treatment programs for veterans with post-traumatic stress disorder (PTSD), military sexual trauma (MST), and Traumatic Brain Injury (TBI), as well as researching biomarkers and complementary and alternative medicine to include cannabis.

The American Legion thanks this committee for the opportunity to elucidate the position of the nearly 2 million veteran members of this organization. For additional information regarding this testimony, please contact Mr. Larry Lohmann, Senior Associate of The American Legion Legislative Division at (202) 861-2700 or llohmann@legion.org.